Healthcare Provider Details

I. General information

NPI: 1679337802
Provider Name (Legal Business Name): WATERFORD DX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 N 55TH AVE STE 100
GLENDALE AZ
85301-3304
US

IV. Provider business mailing address

6830 N 55TH AVE STE 100
GLENDALE AZ
85301-3304
US

V. Phone/Fax

Practice location:
  • Phone: 602-774-2097
  • Fax:
Mailing address:
  • Phone: 602-774-2097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANK AFFINITO
Title or Position: OWNER
Credential:
Phone: 310-503-9177